CCPR: Can you tell us a little about your background?
Dr. Rynn: I’ve been doing clinical research examining new medications for children with anxiety disorders. My passion is working with children who have failed first-line, evidence-based treatments. How do we help these children? What are our options? I look at new treatments or changing the intensity of treatments. We do have good treatments available—it’s just that they don’t work 100% for everybody.
CCPR: Tell us about your take on anxiety.
Dr. Rynn: For us to advance the field beyond the treatments that we have available, we need to think about these illnesses in a different way, understanding more of their biology and expression depending on the environment in which they occur. Children don’t present with just one anxiety or anxiety-related disorder; it’s often more than one. The brain does not recognize our DSM-5 criteria. The circuits that are involved overlap across those disorders, and the environmental interaction brings forth what you see in the child. Under Tom Insel’s leadership, NIMH put forth a multilevel analysis approach, the Research Diagnostic Criteria (RDoC), to examine the range of symptoms—from genomics to circuits and behaviors. It is important to think about core symptoms that can be very problematic for children or adults, cutting across different disorders.
CCPR: Child psychiatrists see patients who report anxiety as a symptom and then typically look for specific diagnoses and then appropriate treatments for these diagnoses. Why is it important to also look at anxiety as a symptom that cuts across diagnostic categories vs differentiating it into specific DSM diagnoses?
Dr. Rynn: Anxiety presents as a core symptom across disorders—mood disorders, disruptive behaviors, and autism, to name a few. Anxiety affects nearly everyone we treat. So, while we need to treat the definable disorders, we also need to figure out how to treat anxiety as a part of these other conditions or situations.
CCPR: How do we address anxiety in all these circumstances?
Dr. Rynn: You need a good assessment that examines all contributors to the symptoms, such as environmental reasons for anxiety; the relationship between anxiety and other problems, for instance anxiety in ADHD when a child is unable to complete homework; and the presence of definable anxiety disorders for which we have defined treatments.
CCPR: And we treat those definable anxiety disorders as we would usually do?
Dr. Rynn: It may depend on the specific child and circumstances, but yes, I would consider applying the usual treatments, as they may have the best chance of helping the anxiety aspect of the situation.
CCPR: We often find in our practices that the parents of the patient have strong or even differing views on medication vs therapy (as well as the patient depending on age). Can you speak to this? How do you decide to go with medication or therapy?
Dr. Rynn: You have to be willing to meet the patient and the parents in their thinking. If they are not comfortable with your recommendations and they come in with their own experiences, that will inform their thoughts about treatment. It is not uncommon for parents to have an anxiety disorder themselves, or for an extended family member or acquaintance to have one: an aunt, uncle, friend, teacher, coach, or clergy member. So keep in mind that a range of people give input to families and children about treatment.
CCPR: How do you speak with parents, knowing there might be this type of preconceived input surrounding treatment?
Dr. Rynn: I like talking to parents about the literature. We know a lot about outcomes if you elect to use a medication vs cognitive behavioral therapy (CBT) vs a combination of these treatments. I want the parents and children to feel empowered to consider their treatment options.
CCPR: Are there any particular studies that you refer to?
Dr. Rynn: The most well-known study—a great accomplishment for the field and NIMH—is the Child/Adolescent Anxiety Multimodal Study (CAMS) study (Walkup JT et al, N Engl J Med 2008;359(26):2753–2766). This was a large, multisite study of 488 children and adolescents that focused on the triad anxiety disorders and mild OCD. We compared sertraline alone (as a representative SSRI, nothing specific about sertraline), CBT alone, and the combination of sertraline and CBT. The study showed we have three efficacious treatments that all separated from placebo. The one caveat is that the medication arm was the only blinded arm—it’s difficult to blind CBT—so to help, independent evaluators were utilized who did not know which research treatment was assigned to the child or family.
CCPR: Was there any difference among the treatment arms?
Dr. Rynn: Those patients who received combined medication treatment with the CBT had the greatest improvement. Some experts in the field have interpreted this to say that you should begin with combined treatment.
CCPR: Do you think combined treatment is the way to go every time, if possible?
Dr. Rynn: In my experience, some families come in and say doing talk therapy is not right for them. Or the child says, “I’m not ready for that, but my anxiety is really problematic. I need something I can just take that will help me.” And so, it is a reasonable choice to start with medication, depending on the clinical context of what is happening for the child. Other families are not comfortable with medication as the first step and want to try CBT. And still other families are dealing with severe symptoms, and for them the combination is the best approach.
CCPR: Is the choice that straightforward?
Dr. Rynn: There are a lot of nuances in regard to the family and presentation of symptoms that come into the clinical decision-making.